St Clare Commons
ST CLARE COMMONS in PERRYSBURG, OH — inspection on March 26, 2026.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation on 03/25/26 at 7:22 A.M. revealed Certified Nursing Assistant (CNA) #300 taking Resident #56's breakfast tray into the room and walking out to continue to pass other resident's trays.Observation on 03/25/26 at 7:37 A.M. revealed Resident #56 sitting up in bed with CNA #300 sitting next to Resident #56's bed. Resident #56's overbed table was in front of CNA #300 and CNA #300 was wearing an earbud in her left ear, visible from the doorway, and was holding her cell phone up while watching a video. CNA #300 was not actively feeding Resident #56.
Concurrent interview with CNA #300 confirmed she was watching social media on her personal phone.
Continued observation revealed CNA #300 asked Resident #56 if she would like eggs. Resident #56 nodded and opened her mouth. CNA #300 fed Resident #56 a bite of yogurt.
Concurrent interview with CNA #300 confirmed she offered eggs and provided yogurt.
Further observation revealed Resident #56's eyes were closed periodically during the meal and CNA #300 would lift a bite of food to Resident #56's mouth and hold it there without notifying Resident #56 she was providing another bite of food.
Alternatively, Resident #56 would open her mouth, possibly in anticipation of a bite of food, and CNA #300 would spend time cleaning off the spoon and attempting to load the spoon with a new bite of food without verbalizing what was happening or about to happen for Resident #56.
Interview on 03/25/26 at 8:02 A.M. with the Interim Director of Nursing (IDON) confirmed staff should not watch their cell phones while providing resident care.
Review of the policy, Meal Supervision and Assistance, reviewed 02/18/26, revealed the facility would provide a relaxing, enjoyable environment during mealtime.This was an incidental finding identified during the Complaint Survey completed 03/26/26.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
366410 03/26/2026
St Clare Commons 12469 Five Point Road Perrysburg, OH 43551
Review of the CAR revealed LPN #221 received
behavior.
Further review revealed LPN #221 was observed on 12/01/25 on video shouting at the resident and using foul/cursing language.
Further review revealed a family member of submitted a written concern on 12/22/25 regarding LPN #221's behavior toward them.
Additional review of the CAR revealed the statement This behavior is disrespectful, abusive and unprofessional.
Interview on 03/26/26 at 12:00 P.M. with the Interim Director of Nursing (IDON) and concurrent review of the CAR confirmed the situation met the criteria for a self-reportable incident due to the description of abusive behavior.
Interview on 03/26/26 at 12:18 P.M. with Human Resources Director (HRD) #313, and concurrent review of the CAR signed 01/01/26, revealed HRD #313 signed the document along with a former Director of Nursing. HRD #313 stated Resident #65 was the resident affected by the behavior identified in the written counseling for LPN #221.
Review of the facility's policy, Abuse, Neglect and Exploitation, approved 05/22/25, defined verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability.
This was an incidental finding identified during the Complaint Survey completed 03/26/26.
366410 03/26/2026
St Clare Commons 12469 Five Point Road Perrysburg, OH 43551
Review of Resident #65's care plan, initiated 07/29/25, and revised 08/12/25, revealed Resident #65 elected to have video monitoring in his room.Review of Resident #65's progress notes, dated 12/01/25 through 12/22/25, revealed no evidence of verbal abuse by staff.
Review of the personnel file, on 03/26/26 at approximately 11:45 A.M., for Licensed Practical Nurse (LPN) #221 revealed a Corrective Action Report (CAR), signed 01/01/26.
Review of the CAR revealed LPN #221 received written counseling for incidents on 12/01/25 and 12/22/25 violating rules of conduct and behavior.
Further review revealed LPN #221 was observed on 12/01/25 on video shouting at the resident and using foul/curing language.
Further review revealed a family member of submitted a written concern on 12/22/25 regarding LPN #221's behavior toward them.
Additional review of the CAR revealed the statement This behavior is disrespectful, abusive and unprofessional.Interview on 03/26/26 at 12:00 P.M. with the Interim Director of Nursing (IDON) and concurrent review of the CAR confirmed the situation met the criteria for a self-reportable incident due to the description of abusive behavior.
Interview on 03/26/26 at 12:13 P.M. with the Administrator, and concurrent review of the CAR signed 01/01/26, revealed she could not determine which resident was involved in the incident.Interview on 03/26/26 at 12:18 P.M. with Human Resources Director (HRD) #313, and concurrent review of the CAR signed 01/01/26, revealed HRD #313 signed the document along with a former Director of Nursing. HRD #313 stated Resident #65 was the resident affected by the behavior identified in the written counseling for LPN #221.Follow-up interview on 03/26/26 at 2:36 P.M. with the Administrator confirmed the facility did not report the incident to the state agency.
Review of the facility's policy, Abuse, Neglect and Exploitation, approved 05/22/25, defined verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability.
Further review revealed the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury.This was an incidental finding identified during the Complaint Survey completed 03/26/26.
366410 03/26/2026
St Clare Commons 12469 Five Point Road Perrysburg, OH 43551
Review of Resident #65's care plan, initiated 07/29/25, and revised 08/12/25, revealed Resident #65 elected to have video monitoring in his room.Review of Resident #65's progress notes, dated 12/01/25 through 12/22/25, revealed no evidence of verbal abuse by staff.
Review of the personnel file, on 03/26/26 at approximately 11:45 A.M., for Licensed Practical Nurse (LPN) #221 revealed a Corrective Action Report (CAR), signed 01/01/26.
Review of the CAR revealed LPN #221 received written counseling for incidents on 12/01/25 and 12/22/25 violating rules of conduct and behavior.
Further review revealed LPN #221 was observed on 12/01/25 on video shouting at the resident and using foul/curing language.
Further review revealed a family member of submitted a written concern on 12/22/25 regarding LPN #221's behavior toward them.
Additional review of the CAR revealed the statement This behavior is disrespectful, abusive and unprofessional.Interview on 03/26/26 at 12:00 P.M. with the Interim Director of Nursing (IDON) and concurrent review of the CAR confirmed the situation met the criteria for a self-reportable incident due to the description of abusive behavior.
Interview on 03/26/26 at 12:13 P.M. with the Administrator, and concurrent review of the CAR signed 01/01/26, revealed she could not determine which resident was involved in the incident.Interview on 03/26/26 at 12:18 P.M. with Human Resources Director (HRD) #313, and concurrent review of the CAR signed 01/01/26, revealed HRD #313 signed the document along with a former Director of Nursing. HRD #313 stated Resident #65 was the resident affected by the behavior identified in the written counseling for LPN #221.Follow-up interview on 03/26/26 at 2:36 P.M. with the Administrator confirmed the facility could not provide evidence of an investigation into the incidents affecting Resident #65 and Resident #65's family member on 12/01/25 and 12/22/25, respectively.
Review of the facility's policy, Abuse, Neglect and Exploitation, approved 05/22/25, defined verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance regardless of their age, ability to comprehend, or disability.
Further review revealed an immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.This was an incidental finding identified during the Complaint Survey completed 03/26/26.
366410 03/26/2026
St Clare Commons 12469 Five Point Road Perrysburg, OH 43551
Review of Resident #60's nursing progress notes and the MAR revealed as needed Ativan was administered on 03/15/26 at 7:33 P.M. with no alternate non-pharmacological interventions documented prior to the Ativan administration.
Interview with the Interim Director of Nursing (IDON) on 03/25/26 at 1:22 P.M. verified the staff failed to complete or document the resident's non-pharmacological interventions prior to the administration of Ativan.
The IDON revealed the facility had no specific policy related to completing non-pharmacological interventions prior to administering psychotropic medications, adding but physician orders must be followed.
This deficiency represents non-compliance investigated under Complaint Number 2727791.
366410 03/26/2026
St Clare Commons 12469 Five Point Road Perrysburg, OH 43551
Review of the medical record for Resident #65 revealed an admission date of [DATE] with diagnoses including migraine, osteoarthritis, heart disease, and Parkinsonism. Resident #65 discharged to another long-term care facility on [DATE].
Review of the physician order initiated [DATE] revealed Resident #65 was prescribed Percocet oral tablet 10-325 mg (oxycodone with acetaminophen) with the resident to be administered one tablet by mouth two times a day, at 9:00 A.M. and 9:00 P.M. for pain.
Review of the physician order initiated [DATE], and not yet discontinued, revealed Resident #65 was prescribed Percocet oral tablet 10-325 mg (oxycodone with acetaminophen), one tablet by mouth every 12 hours as needed for pain at 2:00 P.M. and 2:00 A.M., as needed.Observation of the 200 hall medication cart on [DATE] at 7:27 A.M. with LPN #229 revealed in the locked narcotic drawer of the medication cart there were 22 tablets of Percocet for Resident #65.
Interview with LPN #229 on [DATE] at 7:27 A.M. following the observation of the 200 hall medication cart verified Residents #70, #63 and #65 were no longer in the facility and that each of the residents had narcotic medications in the medication cart.
Interview on [DATE] at 8:23 A.M. with the Interim Director of Nursing (IDON) revealed she was aware expired narcotics remained in the nurse's carts.
The IDON stated the secured drawer in her office was missing the second key and therefore the narcotics could not be stored securely except in the double locked medication carts.
The IDON stated expired narcotics were always destroyed onsite and would require two nurses or a nurse and a pharmacist to destroy the narcotics.Telephone interview Pharmacist #308 on [DATE] at 2:03 P.M. revealed every facility varied as how the narcotics were disposed of for expired and discharged residents.
The Pharmacist stated those medications were not to be kept in the medications carts and should be disposed of as soon as possible.
Review of the facility policy titled Controlled Medications revised on [DATE] revealed discontinued controlled substance medications are removed from the patient care area and temporarily stored at the facility in a securely locked area until such time that they are destroyed as directed by state law.
This was an incidental finding identified during the Complaint Survey completed [DATE].
366410 03/26/2026
St Clare Commons 12469 Five Point Road Perrysburg, OH 43551
are to check the tray prior to serving the food to the resident to ensure they are receiving the correct
366410 03/26/2026
St Clare Commons 12469 Five Point Road Perrysburg, OH 43551
Observation of breakfast service on 03/25/26 at 7:35 A.M. revealed Resident #11 was served pureed sausage, scrambled eggs, pureed toast, and cranberry juice in the appropriate divided place, sippy cup, and build up silverware.
Review of Resident #11's meal ticket dated 03/25/26 revealed the resident would be served yogurt, 1/2 a banana, tea daily, and no juice or soda.Interview with Certified Nursing Assistant (CNA) #208 on 03/25/26 at 7:43 A.M. verified Resident failed to be supplied the ordered food and was served juice. CNA #208 stated the residents' preferences changed often.
Review of the facility policy titled Accommodation of Food Preferences revised 03/25/26 revealed alternate menu items shall be available to accommodate individualized resident needs, food preferences, including religious, ethnic and cultural food preferences, restrictions, and requests.
Resident's food preferences shall be listed in the tray ticket system ither manually or electronically.
This violation represents non-compliance investigated under Complaint Number 2727791.